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The Association of the Nurse Work Environment and Patient Safety in Pediatric Acute Care

Lake, Eileen T., PhD, RN*; Roberts, Kathryn E., MSN, RN, CNS, CCRN, CCNS; Agosto, Paula D., MHA, RN, CCRN; Ely, Elizabeth, PhD, RN; Bettencourt, Amanda P., MSN, CNS, CCRN-K, ACCNS-P*; Schierholz, Elizabeth S., MSN, CRNP, NNP-BC*‡; Frankenberger, Warren D., PhD, RN, CCNS; Catania, Gianluca, PhD, RN; Aiken, Linda H., PhD, RN*

doi: 10.1097/PTS.0000000000000559
Original Article: PDF Only

Objectives Eighteen years ago, the Institute of Medicine estimated that medical errors in hospital were a major cause of mortality. Since that time, reducing patient harm and improving the culture of patient safety have been national health care priorities. The study objectives were to describe the current state of patient safety in pediatric acute care settings and to assess whether modifiable features of organizations are associated with better safety culture.

Methods An observational cross-sectional study used 2015–2016 survey data on 177 hospitals in four U.S. states, including pediatric care in general hospitals and freestanding children's hospitals. Pediatric registered nurses providing direct patient care assessed hospital safety and the clinical work environment. Safety was measured by items from the Agency for Healthcare Research and Quality's Culture of Patient Safety survey. Hospital clinical work environment was measured by the National Quality Forum-endorsed Practice Environment Scale.

Results A total of 1875 pediatric nurses provided an assessment of safety in their hospitals. Sixty percent of pediatric nurses gave their hospitals less than an excellent grade on patient safety; significant variation across hospitals was observed. In the average hospital, 46% of nurses report that mistakes are held against them and 28% do not feel safe questioning authority regarding unsafe practices. Hospitals with better clinical work environments received better patient safety grades.

Conclusions The culture of patient safety varies across U.S. hospital pediatric settings. In better clinical work environments, nurses report more positive safety culture and higher safety grades.

From the *University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research;

Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;

University of Colorado School of Medicine, Denver, CO; and

§University of Genoa, School of Medicine Pharmaceutical Sciences, Genoa, Italy.

Correspondence: Eileen T. Lake, PhD, RN, FAAN, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, 418 Curie Blvd, Rm 302 Fagin Hall, Philadelphia, Pennsylvania 19104-4217 (e-mail:

This study was supported by grants to the Center for Health Outcomes and Policy Research from the National Institute of Nursing Research (T32-NR-007104 and R01-NR-004513, to L.H.A., principal investigator) and from the Children's Hospital of Philadelphia.

The authors disclose no conflict of interest.

Through an analysis of clinician-reported safety, this study suggests that improving the clinical work environment may promote patient safety in the pediatric setting.

Safety events occur in hospitalized children as often as one event every seven admissions. Research has demonstrated that the work environment for clinicians is associated with better patient outcomes, but its association with pediatric patient safety is unclear.

Safety varies considerably across acute pediatric settings. Hospitals with poor work environments have poorer safety. Improving clinical work environments holds promise for achieving a culture of patient safety that increases the reliability of care and prevents harm to hospitalized children.

All authors conceptualized and designed the study, drafted the initial manuscript, revised the manuscript, approved the final manuscript, and agree to be accountable for all aspects of the work.

L.H.A. collected the data and performed the data analysis and interpretation.

E.T.L., K.E.R., A.B., E.S., and W.F. performed the data analysis and interpretation.

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